Review article
The effect of nurse-led education on hospitalisation, readmission, quality of life and cost in adults with heart failure. A systematic review

https://doi.org/10.1016/j.pec.2017.10.002Get rights and content

Highlights

  • Diverse delivery of education sessions are shown to be beneficial when led by a nurse.

  • In adults with HF, higher functioning and QoL are improved with nurse-led education.

  • Nurse-led education of adults with HF reduces hospitalisation.

Abstract

Objective

The purpose of this systematic review was to highlight the effect of nurse-led 1:1 patient education sessions on Quality of Life (QoL), readmission rates and healthcare costs for adults with heart failure (HF) living independently in the community.

Method

A systematic review of randomised control trials was undertaken. Using the search terms nurse, education, heart failure, hospitalisation, readmission, rehospitalisation, economic burden, cost, expenditure and quality of life in PubMed, CINAHL and Google Scholar databases were searched. Papers pertaining to nurse-led 1:1 HF disease management of education of adults in the community with a history of HF were reviewed.

Result

The results of this review identified nurse-led education sessions for adults with HF contribute to reduction in hospital readmissions, reduction in hospitalisation and a cost benefit. Additionally, higher functioning and improved QoL were also identified.

Conclusion

These results suggest that nurse-led patient education for adults with HF improves QoL and reduces hospital admissions and readmissions.

Practice implications

Nurse-led education can be delivered utilising diverse methods and impact to reduce readmission as well as hospitalisation.

Introduction

Heart failure (HF) is a syndrome with a generally poor prognosis, regardless of the use of device therapy and pharmacological interventions [1], [2], [3]. It remains the chief reason for hospitalisation in adults over the age of 65 years [4]. Readmissions, debilitating symptoms and poor QoL are characteristic of patients with HF [5], [6]. Globally, there are approximately 26 million HF patients with the incidence expected to rise 25% by 2030 [1], [7]. In the mild to moderate classification of HF, one-year survival is estimated at 80–90%. However, in severe HF, the one-year survival estimation is 50—60% [8]. The annual cost of HF is approximated at $108 billion worldwide [9]. This is expected to rise owing to an ageing population and increasing prevalence of factors such as obesity [5]. The main expenditure relating to HF is on hospitalisation, followed by pharmacotherapies and community support [10], [11], [12].

Multiple factors contribute to a decline in patients with HF, resulting in hospitalisation and decreased quality of life (QoL). These pertain to the patient, healthcare providers, and health and economical systems [13]. Lack of social support, absence of a partner and living alone constitute a risk for rehospitalisation [6], [14], [15]. Improving self-management skills through disease management programs have shown favourable outcomes in adults with HF, particularly on symptoms, wellbeing, functioning, morbidity and prognosis [16].

Risk models relating to psychosocial factors have been developed to identify and target individuals in risk of adverse events such as rehospitalisation [14], [17]. Due to the limitations in medical treatment and the significant economic burden of HF, primary and secondary prevention strategies including education have been sought [9]. Several disease management programmes have been trialled to reduce cost, hospitalisation and improve QoL of adults with HF [3]. However, these often include a multidisciplinary approach and result in large expenditures [18]. Thus, nurse-led interventions in disease management may prove more cost-effective in HF management. Additionally, self-care has become an important component in HF management with the primary objective of teaching patients self-care, increase compliance and self-efficacy, improve QoL and reduced healthcare costs [8], [19].

The main objectives for HF management are slowing or stopping the progression of HF, managing symptoms and preventing hospitalisation [20]. The practice guidelines in USA, Europe and Australia highlight patient education as a key component in establishing an effective management regimen for adults with HF [20], [21], [22].

Many hospital admissions relating to HF are preventable [23]. Additionally, poor HF related knowledge has been linked to issues such as medication non-compliance [24], [25]. These aspects emphasise the importance of patient education. Ideally, the rationale is to increase patients’ knowledge, which in turn, leads to improved self-care behaviour and decrease adverse outcomes [23] such as hospitalisation and cost.

The study aim was to identify evidence on the effect of nurse-led community education on readmission, hospitalisation, QoL and cost in adult patients with HF.

Patient education is an integral part of a nurse’s role. It has been shown to reduce hospitalisation and readmission. Face-to-face education sessions delivered by nurses to adults with HF have shown to improve disease management knowledge [26]. When comparing the amount of time healthcare providers spend with patients, nurses tend to interact and spend considerably more time with patients. As such, the rapport and relationship nurses build with patients has been shown to influence patient outcomes including adherence to treatment, satisfaction, and understanding of information [27]. Previous literature has identified patient dissatisfaction with physicians not providing understandable explanations of disease management when information was presented to adults with HF [28].

The most appropriate types of studies to address the effectiveness of an intervention are randomised controlled trials (RCTs) [29].To establish this, we reviewed RCTs that included nurse-led education as an intervention in which the end points were readmission, hospitalisation, QoL and/or cost.

Section snippets

Methods

This review is an analysis of RCTs focused on nurse-led 1:1 patient education of adults living in the community.

Search strategy

For the purposes of this review, a comprehensive literature search was conducted with the assistance of a research librarian using the electronic databases CINAHL, PubMed and Google Scholar for RCTs. An initial search was conducted to identify index terms, which were then used in a wide-ranging search. Additionally, further studies were hand searched from reference lists of articles for inclusion. Google Scholar was used to identify grey literature. Only studies published in the English

Type of participants

This review considered all patients 18 years and older, with a diagnosis of HF regardless of severity, duration or co-morbid conditions.

Types of intervention

Studies evaluating community based, nurse-led patient education interventions relating to HF that potentially impacted hospitalisation and hospital readmission rates, QoL and/or cost were considered for inclusion. For this review, nurse-led education was defined as an educational intervention designed towards an individual patient and which was driven and

Assessment of methodological quality

All studies were assessed for methodological quality prior to inclusion in the review. The assessment tool used was the Clinical Appraisal Skills Programme (CASP) tool for RCTs [30]. The CASP tool provides an evidence-based approach for assessing the quality, quantity and consistency of specific study designs [30], [31]. Evidence was appraised systematically through a checklist that contains 11 questions relating to the validity of a study, the outcomes and the usefulness of the results. The

Data collection process

Data from eligible RCTs was extracted and collated in tables. Headings and data collection topics were discussed and agreed on between authors. For the purposes of this review, an electronic data collection tool was not used. Data was collected and is presented in Table 3.

Overview

This systematic review identified that nurse-led patient education had a positive impact on outcome measures. Three studies showed that nurse-led education reduced hospital readmission [32], [33], [34]. Two studies showed that nurse-led education led to a reduction in hospitalisation [35], [36] and one study reported no difference in hospitalisation when compared to usual care [37]. Two studies found that nurse-led education improved QoL [32], [38]. Two studies suggested that nurse-led

Discussion

This systematic review identified seven articles examining the effect of 1:1 nurse-led patient education on hospitalisation, readmission, QoL and cost in community-dwelling adult patients with HF. The results of this review suggest that nurse-led education can improve QoL, reduce hospitalisation and readmission. In addition, two of the four studies included in this review concluded this type of education intervention is cost-effective.

Hospitalisation

The results in this review suggest that nurse-led education

Limitations

Consensus was reached by the authors not to use meta-analysis in this review. A meta-analysis was not considered feasible owing to the diversity of the primary studies included; a factor that can render meta-analysis meaningless [67]. While the CASP tool was used to assess methodological rigour of the included studies, external validity was not measured. The setting of the trials differed (country and community setting); selection of participants (eligibility and exclusion criteria differed);

Author contributions

All authors contributed to the study design and conception, as well as data interpretation. HR was responsible for data acquisition in this review. All authors contributed to data analysis and drafting the manuscript. HR, RS and VB critically revised the manuscript for important intellectual content. All authors gave final approval of the version of the manuscript for submission.

Disclosures

The authors have no relevant financial relationships to disclose.

References (68)

  • J.A. Gazmararian

    Health literacy and knowledge of chronic disease

    Patient Educ. Couns.

    (2003)
  • H.M. Krumholz

    Randomized trial of an education and support intervention to preventreadmission of patients with heart failure

    J. Am. Coll. Cardiol.

    (2002)
  • D. Ferrante

    Long-term results after a telephone intervention in chronic heart failure: DIAL (Randomized Trial of Phone Intervention in Chronic Heart Failure) follow-up

    J. Am. Coll. Cardiol.

    (2010)
  • G. Giamouzis

    Hospitalization epidemic in patients with heart failure: risk factors, risk prediction, knowledge gaps, and future directions

    J. Card. Fail.

    (2011)
  • M. Gheorghiade

    Rehospitalization for heart failure: problems and perspectives

    J. Am. Coll. Cardiol.

    (2013)
  • K.L. Rising

    Emergency department visits after hospital discharge: a missing part of the equation

    Ann. Emerg. Med.

    (2013)
  • A.G. Au

    Predicting the risk of unplanned readmission or death within 30 days of discharge after a heart failure hospitalization

    Am. Heart J.

    (2012)
  • S. Ågren

    Dyads affected by chronic heart failure: a randomized study evaluating effects of education and psychosocial support to patients with heart failure and their partners

    J. Card. Fail.

    (2012)
  • J. Butler et al.

    Worsening heart failure hospitalization epidemic: we do not know how to prevent and we do not know how to treat!

    J. Am. Coll. Cardiol.

    (2008)
  • L.D. Scott et al.

    The effects of nursing interventions to enhance mental health and quality of life among individuals with heart failure

    Appl. Nurs. Res.

    (2004)
  • S. Heo

    Quality of life in patients with heart failure: ask the patients

    Heart Lung: J. Acute Crit. Care

    (2009)
  • J.J. Atherton

    Chronic heart failure: we are fighting the battle, but are we winning the war?

    Scientifica

    (2012)
  • B. Ziaeian et al.

    Epidemiology and aetiology of heart failure

    Nat. Rev. Cardiol.

    (2016)
  • M.L. Luttik

    The importance and impact of social support on outcomes in patients with heart failure: an overview of the literature

    J. Cardiovasc. Nurs.

    (2005)
  • Y. Casimir

    The effectiveness of patient-centered self-care education for adults with heart failure on knowledge, self-care behaviors, quality of life, and readmissions: a systematic review, 2014

    JBI Library Syst. Rev.

    (2014)
  • C. Bonin

    Construction and validation of a questionnaire about heart failure patients' knowledge of their disease

    Arq. Bras. Cardiol.

    (2014)
  • Australian Institute of Health and Welfare, Heart, Stroke and Vascular Diseases − Australian Facts. 2004, Australian...
  • J. Voigt

    A reevaluation of the costs of heart failure and its implications for allocation of health resources in the United States

    Clin. Cardiol.

    (2014)
  • F. Braunschweig et al.

    What are the costs of heart failure?

    Europace

    (2011)
  • V. Betihavas

    An absolute risk prediction model to determine unplanned cardiovascular readmissions for adults with chronic heart failure

    Heart Lung Circ.

    (2015)
  • J. Howie-Esquivel et al.

    Association of parther status and disposition with rehospitalization in heart failure patients

    Am. J. Crit. Care

    (2012)
  • A.S. Desai et al.

    Rehospitalization for heart failure: predict or prevent?

    Circulation

    (2012)
  • G. Nucifora

    Lack of improvement of clinical outcomes by a low-cost: hospital-based heart failure management programme

    J. Cardiovasc. Med.

    (2006)
  • J.J. McMurray

    ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012

    Eur. J. Heart Fail.

    (2012)
  • Cited by (85)

    • What kind of patient education and self-care support do patients with heart failure receive, and by whom? Implementation of the ESC guidelines for heart failure in three European regions

      2023, Heart and Lung
      Citation Excerpt :

      Important reasons for re-admission are low therapy adherence related to medication and diet, and poor self-care such as not seeking medical support when symptoms escalatei.3,4 In order to improve patients’ knowledge and skills, and to influence their attitude and behavior, it is necessary to provide them with adequate Health Care (HC-) professional support.3,6 Multidisciplinary management programs (DMP's) are considered as a key element to improve both the clinical management and patient outcome in HF-patients.7-10

    View all citing articles on Scopus
    View full text